Facility/Physician Telephone Communication Form - altaregional 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Client Name and Date of Birth (DOB) in the designated fields. This information is crucial for identifying the patient.
3. Fill in the Room Number, Facility Name, and Address. Accurate details ensure proper communication within the facility.
4. Provide contact information by entering the Phone and Fax numbers. This allows for efficient follow-up communication.
5. Specify the Physician's name and Date of order. This section is essential for tracking orders accurately.
6. Indicate who took or recorded the telephone order along with their Title. This adds accountability to the process.
7. Select the Reason for call from options like Update, Request for order, or Medication Change. Be specific to ensure clarity.
8. Document any changes in consumer status reported/purpose of call in the provided field.
9. After receiving a response from the physician, enter their response/order and have them sign and date at the bottom of the form.
10. Finally, fax or mail the completed form back to the facility as instructed.

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